Leadership

Treating Low-Income Individuals Is Our Obligation

Interview · June 20, 2017

Steve Corwin and Tom Lee

Read or listen to our interview with Steve Corwin, MD, President and Chief Executive Officer for NewYork-Presbyterian.

 

Tom Lee: This is Tom Lee from NEJM Catalyst, and we’re talking today with Steve Corwin, the physician who is the CEO of NewYork-Presbyterian Hospital. NewYork-Presbyterian Hospital is the biggest hospital in the biggest city in the country. I don’t know if [that is] exactly true, but it sure feels like it’s the biggest hospital in the biggest city in the country. The challenges are tremendous, just making those institutions go and stay among the very best, most respected institutions in the country. But we’re actually talking about something different today than running a great academic medical center. What we’re talking about is a personal and organizational priority of Steve Corwin’s and NewYork-Presbyterian — caring for the indigent.

Now, Steve, this is a time when every hospital I know of is facing rising costs and flat revenues with their insured patients. Why have you made care for the indigent such an important priority?

Steve Corwin: Thanks, Tom, for having me. I think that our institutions, not-for-profit health care institutions like NewYork-Presbyterian, exist for the public good. Part of that public good is delivering care to those populations we serve.

In New York City, as in most areas of the country, there are many who are underserved, and I think it is part of our obligation to society to treat those patients with the same standard of care we give to patients who are commercially insured or have significant wherewithal. It’s just part of what we fundamentally have to do. You’re right. We are faced with flat revenues, rising costs — these are issues — but what we have to do as health care providers is fight our way through this and figure out how to deliver better care, not less care.

Lee: What kinds of interventions is NewYork-Presbyterian implementing, and how are they going?

Corwin: One of the issues for us as health care institutions is to reduce the cost of health care. We can reduce the cost of health care by reducing utilization, and one of the ways that you have to reduce utilization is [to] extend yourself beyond the four walls of the hospital and have community initiatives. I’m aware of so many of the[se] around the country. One such initiative that we have is our Washington Heights and Inwood initiative. This initiative was designed to target frequent users of our services, people with diabetes, other chronic illnesses, asthma in children, and so on, and to try to lessen the utilization by improving their health. We did that quite effectively and published those results.

What we found, however, was that these are expensive mechanisms to reduce utilization. By expensive, I mean putting community mental health workers in place, putting community health workers in place. It’s not particularly scalable. I think our challenge in providing this type of care, the medical homes, if you will, is to do it in a more cost efficient way. That’s why we’re exploring a lot of initiatives around the use of telehealth or telemedicine, however you want to frame those terms.

Lee: It’s an important type of innovation for a great academic medical center that’s created a lot of great innovations in medical sciences, but it does cost money. I’m sure your budget processes are, like the ones that I’ve been through in my career, difficult. That is to say, how do you size the investment? It could be a bottomless pit. The same could be said about education. The same thing could be said about safety. What are your conversations with your CFO like when you talk about how do you size these investments?

Corwin: Let’s go from 30 thousand feet down. I think the first question is, do we think telemedicine is a nice thing to do, or do we think it is an essential thing for us to do? I believe it’s an essential thing for us to do, because I truly believe it will reduce the cost of health care, not increase the cost of health care. So in talking to my CFO about it, this is an investment we have to make. Every other industry has been disrupted by information technology. Health care is already being disrupted by information technology and that will accelerate.

As an academic center, I feel the need for us to be in the lead not because it’s a nice badge, if you will, but because I really think it starts to potentially address the issue of accessibility versus affordability. Our argument in this country has been either we’re going to make care more accessible and we’re going to advance here, or we’re going to make care more affordable to the government as a whole, and that means we’re going to have to cut down on accessibility. We’ve got to break that Gordian knot, and I think telehealth really can do that for us. We can demonstrate that.

I’ll give you a perfect example. We have school-based clinics that we feel very passionately about. At least once a week in these school-based clinics, an adolescent or a child comes in with true suicidal ideation. We have a paucity of child and adolescent psychiatrists in this country, as all of us know, and we’re able to use telepsychiatry to treat these kids and to see these kids. So we have a scalable solution with great child and adolescent psychiatrists that extends beyond the four walls of the institution, that ultimately results in less costs to society. I can go on and on about those types of examples, but that’s why I feel passionately about telehealth.

Lee: The connection between telehealth and covering the indigent — I don’t think I’ve heard it drawn so clearly. And if you’re really going to take care of the indigent I think your conclusion is correct, which is [that] we’re going to have to do it differently than we’ve currently been doing it. I’m glad you’re doing these kind of innovations.

Corwin: Tom, I just want to comment a little bit on that. We’re focusing on what our commitment is to the indigent. I think telehealth will be for everybody, but as a society, it’s going to be important for us not to leave the indigent behind. When you talk about vulnerable populations, be they rural or urban, one of the big issues is Last Mile Broadband. New York City Housing Authority doesn’t have broadband connectivity. You don’t have broadband connectivity in many remote rural areas either, and getting that broadband connectivity to be able to provide telehealth, to be able to scale solutions to leverage the talents in academic centers, is a critical need for the country.

Lee: I was sure that you were doing it for everyone, but I think it could be that the creativity that’s absolutely necessary to care for the indigent is going to teach us about care in general to make it better and more efficient. Let me end by asking you the big, broad question that I’m sure comes up every day or so for you — but your answer would be of great interest to the people who tune into NEJM Catalyst podcasts — I know you’re thinking hard about various scenarios for what will happen with the ACA. I’m sure that the thinking gets tweaked from week to week, but are there any broad outlines of how you’re thinking, how you’re planning when you think about the possibility of major Medicaid cutbacks, for example?

Corwin: Well, needless to say, I think the current discussion on Medicaid cutbacks is ill-conceived. I think it’ll make our society sicker, not healthier, and I think it will add costs to the system because people will be coming into the system at later stages with more advanced illnesses. I think it is poor public policy.

That being said, our philosophy on this is that we’re not going to back off our commitment to our Medicaid population. Thirty percent of our patients are Medicaid patients, so we have to find ways like telehealth to reduce the costs of caring for our vulnerable populations and to provide better care. We also have to use a lot of what we know about process improvements and get costs out of the cost structure of our core hospital. We’re spending a lot of time doing that.

I actually think on the flip side of telehealth, we’re optimistic that artificial intelligence, machine learning, [and] deep neural networks that apply to hospital processes can help us take out those costs. Typically, you’re talking about taking out costs on the cost of supplies and not necessarily the logistics of supplies or revenue cycle or documentation, and not necessarily really streamlining your processes around length of stay by using some of these techniques and thereby reducing the amount of expense associated with process improvements. We’re taking a look at all of that. I think we’re going to all have to take a lot of costs out of health care if these changes go through, but I don’t think we can forego our commitment to the populations that we serve. So we’re just going to have to try to struggle with how to cope with profound cuts and hope that when people see the real human impact of those cuts that some of them will be reversed.

Lee: I want to thank you, Steve. It’s the integration of visionary thinking with [the] real world, having your feet on the ground and having to struggle with budgets and everything. The integration of those two perspectives is a big part of your job, but it’s clear that you’re doing it. I think the rest of health care will learn a lot from what you and your colleagues do at NewYork-Presbyterian.

Corwin: We want to learn a lot from our colleagues around the country as well. I think it’s important for academic centers as a whole to lead and not to follow. I appreciate the time that you gave me today, Tom.

Lee: I’m sure we’ll be coming back and checking in regularly to get more updates from you. Thanks again and thanks to our listeners for tuning in.

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